In this pilot study, we assessed the feasibility of adding a behavioral health screening instrument to the ED workflow and examined self-reported behaviors and symptoms compared with diagnoses documented in the EHR. Similar screening for alcohol and drug use, as well as depression, is performed in the ambulatory setting, but this pilot was the first attempt in this health system to perform this screening in the ED.20,21,31 ED visits represent an important opportunity to identify behavioral health problems, yet systematic screening for these rarely occurs beyond IPV and suicide risk. Opportunities exist in the idle times that patients experience during ED visits to expand screening to more occult behavioral health problems without disrupting workflow.

The screener we tested was not a diagnostic assessment instrument, and endorsement of symptoms does not constitute a diagnosis. Nevertheless, a considerable proportion of screened patients endorsed these symptoms, which adds to our understanding of unrecognized behavioral health problems among ED patients.3,32,33 We incorporated validated screening tools that are widely used in healthcare settings and have relatively high sensitivity and specificity for depression and anxiety: PHQ-2 and GAD-2 have specificities of 76% and 81% and sensitivities of 89% and 76%, respectively. This suggests that a substantial proportion of patients with positive screening would meet diagnostic criteria for these disorders.26,27,34

The ED offers an opportune context for screening for behavioral health issues: Many patients come to the ED in crisis and may be more willing to reveal symptoms of distress that otherwise might remain unidentified and untreated. Additionally, some patients’ only contact with the health system is the ED, leaving these encounters as the sole opportunity to screen them and refer for treatment.

Recognizing that the prevalence of behavioral health symptoms in ED patients is higher than is currently identified is important because these symptoms cause considerable distress and morbidity on their own, exacerbate chronic health conditions, and may result in higher health services utilization and costs. Examples include the adverse effects of alcohol consumption on hypertension and of depression on post–myocardial infarction outcomes, healthcare utilization, and chronic medical conditions.7-9,35 Early identification of these comorbid conditions can help facilitate clinical attention or specialty treatment initiation.36-42 Depression, anxiety, and alcohol or drug misuse are known to adversely impact health outcomes, costs, and utilization. The prevalence of these symptoms that we observed in the ED suggests that expanded screening, with referral and treatment as indicated, would be of value at the individual and health system levels.

Understanding how to effectively implement screening into the ED workflow is challenging. To that end, we examined feasibility and found that having an ED-embedded RA conduct screening was possible and created minimal disruptions to normal clinical workflow. Questions remain about the scalability of systematic screening, which we were unable to address in the absence of additional research funding. Implementing systematic screening into regular ED operations during all 24 hours per day of its operations would require existing staff to assume screening responsibilities or additional personnel, both of which are resource allocation concerns for ED leaders. Clinical response workflows for positive responses (eg, brief interventions, information, referrals to specialty care and/or community resources) are also necessary. As previous studies have shown, large-scale implementation of ED-based Screening, Brief Intervention, and Referral to Treatment for drug and alcohol abuse resulted in widespread adoption and high referral and treatment initiation rates in Massachusetts, but long-term outcomes are unclear.10,43,44

Technology could be leveraged to facilitate the integration of behavioral health screening into the ED workflow. A systematic review of technology-based behavioral health interventions in the ED found high levels of acceptability and feasibility, but limited evidence on efficacy, especially with limited measuring or reporting of clinical outcomes such as decreased IPV incidence or alcohol use.45,46 The optimal approach to behavioral health screening in the ED remains to be determined, but might include some mix of electronic screening with in-person interaction, intervention, and referral.

We found significantly higher levels of self-reported depression and anxiety symptoms, risky alcohol and drug use, sleep problems, and chronic pain compared with documented diagnoses. Although screening is by nature less specific than a formal assessment and diagnostic process, the magnitude of differences identified supports the findings of previous research suggesting that ED patients may have higher prevalence rates, and lower rates of detection, than the general population.5,32,33,47,48 Similar discrepancies between prevalence of diagnoses and positive screening for behavioral health conditions have also been found among primary care patients, especially among patients with lower utilization of health services.5,49 As such, the ED may be the only opportunity to screen for and detect behavioral health problems in this subset of patients with limited healthcare contact. Performing screening in the ED would leverage that healthcare contact to allow appropriate and timely referral to primary care, mental health, or drug and alcohol treatment.

Our screened cohort was not identical to the eligible population. The differences, however, were minor and to be expected with convenience sampling, limited hours, and our small sample (4% of similar ED patients). The 2 groups had small racial/ethnic and age differences, and the screened sample had more medical comorbidities, higher overall CCI scores, and higher prevalence of depression and panic disorders. Chronic medical conditions are known to be associated with increased prevalence of depression and anxiety disorders, which may partially explain the higher observed prevalence in the screened population.35,50 However, the observed rates of positive depression and anxiety screens are similar to those that have been reported in other studies of ED patients.2,4,33

Limitations

As this was a feasibility study, research staff hours were limited and we were unable to serially screen every eligible patient. We did not approach patients seen in the fast-track section of the ED, who represent up to 40% of ED patients, nor were patients with truly emergent medical problems screened. Because participation was voluntary, patients self-selected into or out of screening. All of these limitations introduce the potential for bias, and the screened sample may not be representative of all ED patients in both measured and unmeasured variables. Although we were unable to compare self-reported symptoms between the 2 groups, we did compare self-reported symptoms with their past-year diagnoses, and we found higher proportions of medical, depression, and panic disorder diagnoses among the screened group. It may be that eligible patients who were more severely ill spent longer in the ED and thus had more time to be approached for screening, or that their medical or mental health problems made them more willing to be screened.

Although this facility is subject to the same regulations governing all EDs in the United States and thus accepts all patients, for these analyses, we limited the sample to health system members in order to have access to their EHR data. Because this is a private, nonprofit healthcare delivery system, its population may not be representative of ED populations in public systems.

CONCLUSIONS

Our findings from this pilot study suggest that ED patients may experience relatively high rates of emotional distress and behavioral health problems—higher than suggested by the diagnoses documented in the EHR. ED visits may offer an important clinical context for screening for these concerns. Brief screening for common behavioral health problems in the ED setting proved feasible in this convenience sample, which was supported by research funding. However, implementing universal screening would require additional investments in personnel or adding to the work of existing staff, as well as implementing pathways for further brief intervention, referral, and treatment. Adding brief intervention and referral in coordination with outpatient referral resources would likely be more efficacious than simple screening.